=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699816223
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RALEIGH FAMILY DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2007
-----------------------------------------------------
Last Update Date | 02/25/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3068 COVINGTON PIKE SUITE 2
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38128-5001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-386-2328
-----------------------------------------------------
Fax | 901-382-1538
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3068 COVINGTON PIKE SUITE 2
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38128-5001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-386-2328
-----------------------------------------------------
Fax | 901-382-1538
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | MS. RHONDA D CURRY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 901-386-2328
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 4532338
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------